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Re: My most stressful case this week! (obs)From: Griffiths Malcolm (Malcolm.Griffiths@ldh-tr.anglox.nhs.uk)Wed Jul 19 17:16:01 2000
I had a case a week ago on Wednesday. Patient is at term with previous term normal vaginal delivery. A (previously undiagnosed) breech is found at 6cm in rapidly progressing labour. Senior resident diagnoses footling but by then she's 8cm. I am called. Couple are keen to avoid CS and in our unit there is no blanket ban on footling breech vag deliveries (strikes me there is no need to debate that as in fact it has no real bearing on the problems of this case). She is progressing so quickly that when I see her I think she is probably fully dilated. I suggest we move to theatre and put in a spinal. Aim for vag del but set up for CS. This all happens very quickly, but spinal is not easy and has to be abandoned because breech is now crowning. The breech delivers without traction and no real maternal effort to just beyond the umbilicus. There is then no further descent at all. Lovset's manoeuvre failed - the trunk wasn't really low enough, nether shoulder was in the pelvis. I was unable to get above either shoulder to bring one down. Traction was ineffective as was maternal pushing. At this point I had the partner taken outside and asked for a GAB. Under GA it was almost as difficult. I was though able to disimpact the left arm. In the meantime I had instructed my senior resident to start CS. Patient was still in lithotomy. Once uterus was open we could not deliver the head. This was despite pushing up on baby, forceps, putting legs down. Accordingly I got my SR to help me push the remaining nuccal arm down across the fetal face & chest so that I could disimpact it below. Then I easily delivered the head by MSV. I should point out that this was not a problem of footling breech coming through an incompletely dilated cervix. The cervix was definitely fully on vaginal and abdominal examination. The problems was of two nuccal arms in a good sized (3.9Kg) breech. There was concern about this being due to a decision to allow vaginal delivery. IN fact if we had decided on vaginal delivery the same sequence would have happened. She would have been taken to theatre. The anaesthetist would have failed to have got the spinal in before the breech delivered, the arms would have been misplaced. My understanding has really been that nuccal arms arise as a result of traction and stimulation of the baby and don't occur if management is hands off - I may be wrong! Any comments? Needless to say the babe was born assystolic and was resuscitated including adrenaline to restart the heart. Cord pH was 7.174 - obviously not really reflecting fetal status as the cord was occluded for most of this time. I was very frank in my conversations with the parents and warned about HIE CP etc. Baby has done really well. He did not fit. He has been cardiovascularly stable. He was taken off ventilator after <24 hours. He commenced feeds today (aged 48h). He seems possibly to have a mild brachial plexus injury but no bony problems. He is somewhat bruised! I think I have had a very near miss and don't want to repeat this experience for a long time!
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